whitebook medical care of the severely injured 1 deutsche gesellschaft für unfallchirurgie e. v....

Deutsche Gesellschaft fr Unfallchirurgie e. V.Supplement 1June 2012

WhitebookMedical Care of the Severely Injured2nd revised and updated edition

Recommendations on structure, organization, installations and equipment to promote quality, safety and reliability in the medical care of the severely injured in the Federal Republic of Germany

SupplementOrthopaedics and traumatologyCommunications and News

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Medical Care of the Severely InjuredMedical Care of the Severely InjuredMedical Care of the Severely InjuredMedical Care of the Severely Injured

Recommendations on structure, organization, installations and equipment to promote quality, safety and reliability in the medical care of the severely injured

in the Federal Republic of Germany

2nd revised and updated edition

SupplementSupplementSupplementSupplement

Orthopaedics and traumatology

Communications and News

A project within the Initiative for Quality and Reliability in Orthopaedics and Traumatology of

the German Society for Trauma Surgery (registered association) and

the Professional Association of Orthopaedic and Trauma Specialists

PublisherPublisherPublisherPublisher:::: German Society for Trauma Surgery (reg. assoc.), Berlin

Status May 2012

2nd revised and updated edition


Collaborators Revised by: Whitebook Implementation Group:

Bertil Bouillon Sascha Floh Christian Khne Sven Lendemans Steffen Ruchholtz Hartmut Siebert

With the collaboration of (in alphabetical order): Volker Bhren, Murnau Karsten Dreinhfer, Berlin

Reinhard Hoffmann, Frankfurt/M. Peter Kalbe, Rinteln Bernd Kladny, Herzogenaurach Christian Lackner, Munich Jrgen Probst, Murnau Julia Seifert, Berlin

Dirk Sommerfeldt, Hamburg Dirk Stengel, Berlin Klaus Michael Strmer, Gttingen Johannes Sturm, Mnster Norbert Sdkamp, Freiburg

Peter Voigt, Hannover Michael Walz, Eschborn Christian Waydhas, Essen

Acknowledgements We sincerely thank Prof Dr. Jrgen Probst, Murnau, for editing the manuscript and for his many

valuable comments. Likewise many thanks go to the staff of the DGU main office, namely, Ms Susanne Herda and Ms Daniela Nagorka, and also to Ms Catrin Dankowski at the AKUT main office for their superb secretarial

work.


These recommendations have been agreed with the following specialist societies and associations:

German Association of Rescue Services, German Society for Vascular Medicine and Surgery,

German Society for Cardiac, Thoracic and Vascular Surgery, German Society for Paediatric Surgery, German Society for Neurosurgery, German Society for Orthopaedics and Orthopaedic Surgery, German Society of Plastic, Reconstructive and Aesthetic Plastic Surgeons,

German Society for Thoracic Surgery, German Society for Radiology, German Society for Urology, DIOcert Ltd, Mainz

For invaluable advice we thank: Association for Specialists in Orthopaedic and Trauma Surgery, Federal Bureau for Quality Assurance Ltd, German Society for Anaesthesia and Intensive Care, German Society for General and Visceral Surgery,

German Society for Surgery


Preface to the 2nd revised and updated edition The publication of the first Whitebook in autumn 2006 stimulated intense, long-term discussion of the organization and availability of medical care for the severely injured in Germany. To address the inadequacies that came to light and to implement the published recommendations, the German

Society for Trauma Surgery initiated the project TraumaNetzwerk DGU (TNW). The task of

implementing the project was assigned to the Whitebook Implementation Group / TraumaNetzwerk (AKUT).

The aim of the TNW is to form a structured nationwide network of approved clinics qualified to deliver

medical care to the severely injured in compliance with uniform care and quality standards. This This This This should guarantee that every severely injured person has the same chances of survival at all times and should guarantee that every severely injured person has the same chances of survival at all times and should guarantee that every severely injured person has the same chances of survival at all times and should guarantee that every severely injured person has the same chances of survival at all times and in all placesin all placesin all placesin all places in Germany in Germany in Germany in Germany....

In 2007 the panel of experts monitoring changes in the health system adopted the recommendations

set out in the Whitebook and recommended them to other medical disciplines as a model of structured and interlinked emergency care. In the meantime, the TNW project has been integrated into hospital planning requirements in a drive to ensure emergency medical care in the individual federal states.

The decision to publish a 2nd revised edition of the Whitebook was taken in response to changes in

the health system environment, the experience acquired during implementation of the TNW project, and the insights gained during compilation of the interdisciplinary S3-Guidelines of the German Society of Trauma Surgery on the care of the severely injured..

The recommendations for the care of severely injured children and severe burn patients as well as a

chapter on early rehabilitation and outpatient follow-up treatment are new in this edition.

Furthermore, representatives from numerous institutions, specialist societies and associations have

collaborated on this 2nd edition of the Whitebook.

We express our sincere thanks to all those who contributed to the preparation and compilation and, in particular, we thank all the specialist societies, associations and experts listed in the front matter for their valuable comments and important contributions.

Christoph Josten President DGU

Hartmut Siebert Secretary General DGU Steffen Ruchholtz Spokesman AKUT

Berlin, May 5, 2012


NotesNotesNotesNotes::::

All official titles in these Recommendations, including titles of status and function that appear to be gender-specific are to be understood as referring to men and women alike.

Comments and suggestions with regard to clarity of meaning, misunderstandings or errors will be gratefully received. We ask you to direct your communications to the main office of the German Society for Orthopaedics and Trauma in Berlin.

This Whitebook will be updated at relevant intervals in response to changes in legal and economic regulations and conditions, medical developments and to reflect the ongoing practical experience being gained in the process of implementing these

recommendations as part of the project TraumaNetzwerk DGU.


Table of Contents

1 Introduction 6

1.1 References 6

2 Overview 7

2.1 Medical Care Infrastructure for the Severely Injured in Germany 7

2.2 Data on mechanisms, frequency and consequences of accidents and factors affecting quality of care 7

Epidemiology of severe trauma 7

Severely injured children 8

Burn injuries 9

2.3 Reformed Health Care Structure 9

Framework Law 9

Continuous Professional Development in the Care of the Severely Injured 9

2.4 References 10

3 The concept of the TraumaNetzwerk DGU 13

3.1 Preliminary Remarks 13

3.2 Components of a Trauma Network 13

3.3 Clinics in the Trauma Network 14

Local Trauma Centre (TC) 14

General Characteristics Local TC 14

Responsibilities within a TNW Local TC 14

Quality standards for infrastructure and procedure Local TC 14

Regional trauma centre 15

General characteristics Regional TC 15

Responsibilities within the Trauma Network Regional TC 15


Quality standards for infrastructure and procedure Regional TC 15

Regional TC without its own neurosurgery clinic 16

Supraregional Trauma Centre 17

General Characteristics Supraregional TC 17

Responsibilities within the Trauma Network Supraregional TC 17

Quality standards for infrastructure and procedure Supraregional TC 17

Quality standards for infrastructure and procedure at an intensive care unit Regional TC and supraregional TC 18

3.4 Care of severely injured children (up to 15 years of age) 19

Paediatric trauma referral centre 19

3.5 Care of the severely burned in the TNW 19

3.6 References 20

3.7 Rehabilitation of the severely injured within the TNW 20

Inpatient Rehabilitation 20

Responsibilities within the Trauma Network 20

Quality standards for infrastructure and procedure 20

References 20

3.8 Outpatient follow-up treatment within the TNW 21

Quality standards for infrastructure and procedure 21

Interaction between inpatient facilities and the recipient doctors 21

4 Networking between clinics 22

4.1 Interaction of the clinics participating in the Trauma Network 22

4.2 Interhospital communication 22

4.3 Telecommunication within the Trauma Network (Telecooperation) 22

4.4 Criteria for onward transfer 23

4.5 Networking between preclinical and clinical care facilities 24


Criteria for admission to the emergency room of a trauma centre with activation of the emergency room team 24

Handing over the injured person and documentation on preclinical treatment 24

4.6 References 25

5 Quality and reliability of care for the severely injured 26

5.1 Strategies to promote quality and reliability 26

Trauma Centre 26

Trauma Network 27

5.2 Evaluation of outcome quality TraumaRegisterDGU 27

5.3 Evaluation of neurotraumatological outcome quality 27

5.4 Organization of the implementation of the TraumaNetzwerk DGU project 28

5.5 Auditing and certification 28

5.6 Clinical research and health care research 29

5.7 References 29

6 International Cooperations 29

6.1 Decade of Action for Road Safety 20112020 announced by the WHO 29

6.2 Cross-border Trauma Networks 29

Appendix 30

I. Required facilities and installations for local, regional, and supraregional TCs (emergency admissions and operating rooms 30

II. Additional information on the care of the severely burned within the TNW 31

III. Detailed information and comments on the rehabilitation of the severely injured 32

IV. Remarks on Telecommunication (telecooperation) within the TNW 34


List of Abbreviations ADAC German Automobile Association

AHB Follow-up Treatment

AIS Abbreviated Injury Scale

AKUT Whitebook Implementation Group / TraumaNetwork of the DGU

LRD Medical Director Rescue Services

ATLS Advanced Trauma Life Support

AUC Academy for Traumatology Ltd

BG Trade Association (Industrial Liability and Accident Insurance)

BGSW BG Inpatient Follow-up Treatment

CT Computer tomography

D-Arzt Accident Insurance Consultant

DGUV German Statutory Accident Insurance

DICOM Digital Imaging and Communications in Medicine

DIVI German Interdisciplinary Association for Intensive Medical Care

DRG Diagnosis Related Groups

DSO German Foundation for Organ Transplant

DSTC Definitive Surgical Trauma Care

EAP Enhanced Outpatient Physiotherapy

EFL Evaluation of Functional Performance

EKG Electrocardiogram

ERGOS Work simulation system

ETC European Trauma Course

MS Medical Specialist

GCS Glasgow Coma Scale

GKV Statutory Health Insurance (SHI)

GMG Health Care Reform Act

GSG Health Care Structure Act

GUV Statutory Accident Insurance

HOTT Hand Over Team Training

HNO Ear, Nose and Throat Therapy


ICF International Classification of Functionality, Disability and Health

INM Institute for Emergency Medicine and Medical Management

ISS Injury Severity Score

KTQ Cooperation for Transparency and Quality in the Health System

KV Health Insurance

LTZ Local Trauma Centre

MRT Magnetic Resonance Imaging

NIS DGU Section for Emergency Medicine, Intensive Care and Care of the Severely Injured

OPS Operations and Procedures Code

PHTLS Pre Hospital Trauma Life Support

Reha Rehabilitation

RTZ Regional Trauma Centre

RV Pension Insurance

SGB V Social Security Code V

SHT Craniocerebral Trauma

SP Specialism

TNW TraumaNetwork

TR TraumaRegister

TZ Trauma Centre

RTZ Supraregional Trauma Centre

WA Specialty registrar

WHO World Health Organization

ZMK Dental, Oral and Maxillofacial Surgery


1 Introduction Accidents can happen to anyone and are by definition unexpected. They can happen anywhere at any time. Accidents may involve one person or several people or may be heavy casualty events. Accident prevention, emergency treatment of the injured, restorative and corrective interventions, replacement

of body parts and restoration of functional ability as well as rehabilitation with the aim of social and professional reintegration of the injured person are humanitarian, social and economic responsibilities of the highest order.

To ensure the nationwide long-term provision of high performance, quality-assured medical care of the

severely injured around the clock, the new, revised and updated edition of the Whitebook sets out recommendations not only for infrastructure, installations, equipment, and organization, but also reliability and quality of care for severely injured patients of all ages.

Quality and Reliability in the care of the severely injured can only be achieved through the nationwide

provision of high-performance care facilities that can treat any injury to any person around the clock. This requires structured regional medical care systems within which there is a pre-planned, well coordinated close-knit cooperation of rescue services, clinics, rehabilitation facilities and doctors in independent practice. Trauma centres are pivotal elements that have proven to increase the quality of infrastructure, processes and treatment outcomes for the severely injured. The concept of networking

was put into practice in 2007 in the form of the ongoing TraumaNetzwerk DGU project.

In accordance with regionally defined requirements, adequate capacity and relevant specialists are to be provided in suitable medical care centres within each Trauma Network. Apart from orthopaedic and

trauma experts, the many other requisite operative and non-operative specialisms include anaesthesiology and emergency medicine, radiology and interventional radiology, general and visceral surgery, neurosurgery and neurology, cardiac, vascular and thoracic surgery, plastic surgery, oral maxillofacial surgery, ear nose and throat therapy, paediatric surgery, ophthalmology, psychiatry and psychology, urology and gynaecology.

A smooth collaboration between preclinical rescue operations, emergency doctors, other institutions

(e.g. the fire brigade) and the trauma centres within the network is as essential as the structured interaction between emergency clinics, rehabilitation centres and facilities for outpatient follow-up treatment.

Only clearly task-oriented networks can offer guaranteed accessibility to all the necessary specialists and optimal utilization of the available resources. Provision of adequate medical care facilities is a primary concern of those immediately involved and of the regional authorities legally responsible.

The endeavours presented here support the Decade of Action for Road Safety 20112020 (DARS) as

called for by the World Health Organization as well as flanking programmes and projects of various national and international organizations and associations within the EU to optimize cross-border cooperation in the care of the severely injured.


The recommendations in the Whitebook serve

- to optimize the care chain from the scene of the accident to reintegration, - to facilitate the gradual realization of a network for the medical care of the severely injured

(TraumaNetzwerk DGU),

- to ensure realistic, long-term regional and cross-border planning of hospital requirements, - to promote definitive internal and external quality assurance and patient safety, - to contribute to disaster prevention, - to maximize utilization of resources on the basis of medical and economic necessity and

developments.

In this endeavour the findings and insights of the following institutions and associations were taken

into account: - Federal Offices for Health and Safety at Work and Industrial Medicine, - Federal Road and Transport Office (BaST), - Federal Office for Quality Assurance (BQS),

- German Statutory Accident Insurance (DGUV), - German Interdisciplinary Association for Intensive Medical Care (DIVI), - Federal Health Reports, - Institutes of the Lead Associations of the Statutory and Private Health Insurers (GKV, PKV), - Institutes of the German Hospital Federation (DKGI),

- Robert Koch Institute (RKI), - Federal and State Statistical Offices (StBA), - DGU Guidelines for the Care of the Severely Injured,

- TraumaRegister DGU,

- American College of Surgeons (ACS).

1.1References 1 Celso B, Tepas J, Langland-Orban B et al. A systematic review and meta-analysis comparing outcome of

severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006; 60 (2): 371378

2 MacKenzie EJ, Rivara FP, Jurkovich GJ et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006; 26; 354 (4): 366378


2 Overview

2.1 Medical Care Infrastructure for the Severely Injured in Germany

Preclinical and clinical care of severely injured patients in Germany is of a high standard due to the immense dedication of all the participating professional groups and specialists [1].

That said, some specific accidents have led to intense public discussion and a number of scientific

studies indicating that the quality of care for the severely injured in Germany is not yet homogeneous [24]. For example, reports from the Federal Statistics Office show that the incidence of fatal road accidents varies greatly across the different federal states. The statistics reveal that the mortality rate after road accidents involving personal injury in Mecklenburg-Vorpommern is 1.6% compared with

0.8% in North Rhine Westphalia (Federal Statistics Office 2010). However, it should be noted that a hospital in Mecklenburg-Vorpommern has a catchment area of 4634km2 compared with 541km2 in North Rhine Westphalia. Furthermore, detailed study of the data stored as part of the TraumaRegister of the German Society for Traumatology (DGU) has shown clear differences in mortality rates after severe trauma at their member hospitals [4].

There are two main reasons for these differences in quality: - differences in geography and infrastructure between regions, and - differences in professional expertise, care facilities and treatment concepts in the different

hospitals.

Before the TraumaNetzwerk DGU project started in 2006 the structures and processes for the care of

the severely injured in Germany were guided by conditions laid down by the statutory accident insurance companies, state-specific political regulations and strategies for the professional development of all specialisms and professional groups involved in the care of the severely injured

patient.

The TraumaNetzwerk DGU project aims to improve the quality and reliability of care for the severely

injured nationwide in Germany with the support of all specialist disciplines, professional groups and

associations that participate in the care of the injured based on the recommendations of the Whitebook.

Since the start of the project in 2006 864 clinics in 53 regional Trauma Networks have participated in this quality initiative. 31Trauma Networks with 413 participating clinics have already completed the

certification process successfully. A further 132 clinics have successfully passed through the auditing procedure and are awaiting certification of their regional Trauma Network. Another 17 clinics in neighbouring countries are integrated into cross-border cooperation agreements (at the time of printing, up-to-date information on www.dgu-traumanetzwerk.de).


Parallel research projects have already found evidence of first improvements in the quality of

infrastructure and processes in the regional Trauma Networks. This includes standardization of emergency room installations, implementation of interdisciplinary treatment guidelines and improved cooperation between centres [5]. Data on outcome quality are not currently available.

2.2 Data on the mechanisms, frequency and consequences of accidents and factors affecting quality of care

Epidemiology of severe trauma In Germany accidents are in fifth place in the statistics for cause of death and in first place as the

cause of loss of potential life. From a socio-economic point of view death by accident is more relevant than malignant neoplasm or cardiovascular disease! Studies in the USA identified an average loss of 35 years of potential life after trauma, whereas malignant neoplasms led to 16 years and cardiovascular disease to 13 years loss of potential life [6].

Germany can expect up to 38,000 severely injured persons annually (i.e. persons with an Injury

Severity Score [ISS] 16) [7]. In addition, at least an equal number of less severely injured persons are likely to present for treatment (ISS


the cost of primary treatment. Preclinical and clinical treatment accounted for 5% and follow-up

treatment for 29% of the total costs. The remaining 66% is the result of loss of productivity.

Treatment outcomes for the severely injured Treatment outcomes for the severely injured Treatment outcomes for the severely injured Treatment outcomes for the severely injured Clinical experience and scientific data suggest [3,29,32] that outcomes for the severely injured are

decisively and lastingly affected by - the treatment-free interval, the duration of preclinical care and the level of expertise applied (in the

sense of the shortest possible rescue time), - the 24-hour availability of comprehensive emergency diagnostics (e.g. CT, interventional

radiology) and treatment (interdisciplinary emergency and OR management, special OR teams), - excellent intensive care and immediate access to complementary surgical specialists (e.g.

neurosurgery, visceral surgery, vascular and cardiac surgeons), - early commencement of holistic rehabilitative therapies.

Studies carried out in the USA in the 1970s found that the quality of trauma care was better in specialized centres in the sense that less preventable deaths occurred [33,34]. This led to the introduction of designated and accredited trauma centres at different levels of care (Trauma levels 1

4). The idea behind this policy was that all persons with very serious injuries should be taken to a specialized trauma centre [3542].

Scientific proof of the efficacy and benefit of introducing trauma centres is extensive and convincing. Celso undertook metaanalysis and found that establishing trauma systems had led to a reduction in

trauma mortality in the USA [43]. This result has been confirmed by later studies [4446]. Analysis of the National Trauma Data Bank also revealed better functional outcomes (based on the Functional Independence Measure, FIM) and a higher rate of long-term completely independent trauma survivors after treatment at a specialized centre [47].

In the literature there is controversial discussion as to whether a minimum number of cases improves

outcomes for the severely injured [4853].

In summary, current literature does not offer any evidence that a minimum case number is important

or that there is a clear relationship between case number and outcome.

The most recent evaluation of the TraumaRegister DGU (2010) in Germany concluded that on

average 57 severely injured patients (ISS 16) were treated annually at a supraregional trauma

centre, 28 at a regional trauma centre, and six at a local trauma centre [8].

A comparison of the international literature with the afore-mentioned data from the TraumaRegister (TR) also suggests that it is important to discuss greater centralization in Germany. If the number of severely injured is assumed to be 38,000 with an average stay of 11 days in the intensive care unit [8]

then far more ICU beds are needed at the individual centres. Assuming 100 trauma centres in Germany this would mean that each of these centres would require 12 beds permanently set aside for


the intensive care of the severely injured. This would, in turn, mean radical restructuring of the hospital

landscape. Therefore, the project TraumaNetzwerk DGU gave preference to the alternative concept

of integrating approved trauma centres for different levels of care into regionally coordinated networks.

This structure has provided a densely populated country with an integrated nationwide system of

approved trauma centres, organized into networks and operating at a standardized and approved level.

Severely injured children

Statistics from the TraumaRegister DGU (20062010) show that about 1500 patients aged between

015 years require treatment for severe injuries in Germany every year. The highest percentage of severely injured children and adolescents are aged 11 to 15 and account for almost 50%, 30% are aged 0 to 5 years, and 20% are 6 to 10 years.

The most frequently injured region is the head. Between 67 ands 78% of children (depending on age

group) suffer cerebrocranial trauma (CCT) with an AIS 3. The number of severe cases of CCT is therefore much higher than for adults (58%). Injuries to the chest (32 to 45%) and to the extremities (21 to 34%) are less frequent than in adults (56%). Between 17 and 26% of affected children have suffered serious abdominal injuries in contrast to 22% of adults. Relevant pelvic and spine injuries (AIS2) are likewise less than for adults (921%). Overall the mechanisms of injury and the injury

patterns gradually approximate to those of adults as age increases [7,53].

Although no additional comparative data are available for Germany, findings from international studies suggest that the injured child will receive better care if the availability of the relevant experts is

integrated into the special organization for the care of severely injured persons. In reality this means that paediatric trauma specialists need to be definitively linked into the system of approved trauma centres [5579]. For this reason, this revised edition of the Whitebook includes the special infrastructure, organization and professional expertise required to treat these young patients.

Burn injuries Every year about 1400 adults are treated for severe burns at special hospitals. The cost of treatment is high and can run to several hundred thousand Euros for one individual. Comprehensive expert treatment requires appropriate wound treatment at all stages and state-of-the-art skin grafting to achieve best possible functional and aesthetic restoration as well as early social and professional

rehabilitation and reintegration.

The severely burned patient needs qualified multidisciplinary and multiprofessional treatment in line with current standards clearly defined by national and international specialist societies [8091].

In the Federal Republic of Germany the number of beds in specialized centres complies with

international recommendations on adequate care standards (1 ICU bed per 1Mio. inhabitants) (www.verbrennungsmedizin.de). A network of specialized burn centres is provided in Germany to


accommodate these special cases. Networking between the trauma centres and the centres for the

severely burned is an essential part of the TraumaNetzwerk DGU project.

2.3 Reformed Health Care Structure

Framework Law The basic economic and section-related framework for the care of the injured is governed mainly by

various statutory regulations such as - the GKV/GHI Statutory Health Insurance and Health Care Structure Act (GKV-VSG) 2011, - German Diagnosis-Related Groups System (G-DRG-system), - Social Security Code V (SGB V),

- Working Hours Act (ArbZG), - Social Security Code VII (SGB VII) (special medical care of the German Statutory Accident

Insurance (DGUV) with updated guidelines on the practice of medical care, - Health Care Reform Act (GMG), - Hospital Funding Act (KH-FiG),

- special federal state legislation (e.g. hospital requirement planning, rescue services)

These and other conditions such as limited government funding for the necessary investments, e.g. for

heavy medical equipment and/or building projects, have led to increased concentration on specific, achievable services in the outpatient and inpatient sectors in an effort to minimize cost and optimize resources.

According to a study conducted in 2009 and 2010 the German Diagnosis-Related Groups System (G-

DRG), which changes every year, only adequately covers 23 to 34 of total expenditure on emergency treatment of the severely injured due to inconsistent allocation of a severely injured person to the diagnosis groups that determine income [95,96].

To optimize the G-DRG system there is a need to improve its allocation precision so that complex and

heterogeneous groups of severely injured persons can be identified by the grouping mechanism.

Studies conducted by leading rescue organizations together with treatment data from some of the

main casualty departments in specific regions of the Federal Republic of Germany, as presented at the DGOU Forum Centralized Emergency Admissions in June 2010, indicate that modification or restructuring of in- and outpatient emergency care, especially outside normal working hours, leads to a tangible accumulation of emergency care needs at specialist centres so that the facilities are over-stretched and capacity for the severely injured is limited.


Continuous Professional Development in the Care of the Severely Injured Constant progress in medicine and increasing specialization led to a change in the Model Regulations on Specialty Training (MWBO) in 2003. Surgery as a discipline is divided into 8 specialist qualifications

combined with supplementary specialist qualifications based on general advanced surgical training (common trunk). Specialist qualification in orthopaedics and traumatology requires a 4-year advanced course and a 2-year basic surgery course. The in- and outpatient care of casualties is one of the core areas of orthopaedic and trauma surgery. This responsibility includes provision of comprehensive services for emergency care 24 hours a day on 365 days of the year, delivery of

appropriate specialist care to the injured person and, in some cases, ensuring the delivery of such care by collaboration with other medical disciplines. The complexity of severe injury often requires joint multidisciplinary multi-stage treatment.

The treatment chain is made up of preclinical rescue, emergency room management, emergency care,

surgical and non-surgical interventions to achieve definitive restoration, including rehabilitation to the level of professional and social reintegration. The advanced in-depth training course on Special Trauma Surgery lasts at least two years after qualification as a specialist and imparts specialist knowledge concerning the treatment of injury and its consequences, and includes insights and experiences in the care of the severely injured and management of the treatment processes.

It will not be possible in the long-term to have the right specialist on duty or on call at all times for all injuries, particularly as this often means several specialists for one patient. Advanced training as a specialist for orthopaedics and traumatology, especially the in-depth supplementary qualification in Special Trauma Surgery, is there to ensure that a broad knowledge is acquired as well as specialist

training. This presupposes that generalists as well as specialists will be provided by the hospital structures to support and assist each other for the benefit of the patients. The generalists will learn continuously from the specialists and vice versa. This ensures that the generalists work at a high level and the view of the specialist does not become too narrow [97,98].

It also means that despite increasing specialization, generalists, i.e. well qualified specialist doctors

with broad-based advanced training who can take responsibility round the clock even within the specialism of orthopaedics and traumatology, should continuously receive up-to-date professional training.

The multiplicity of possible traumatopathies (e.g. abdominal trauma) highlights the necessity of

imparting knowledge and experience through advanced training courses in Special Trauma Surgery not only in the area of orthopaedics and traumatology, but also in the related disciplines involved in the care of those requiring special surgery.

Communication of superior knowledge and experience in the context of process-steering and overall

responsibility is the special task of the clinics authorized to teach orthopaedics and traumatology.

Experience gained in recent years during implementation of the TraumaNetzwerk DGU has shown


that a regional network of clinics with different care specialisms, including facilities for early

rehabilitation, constitutes an extension of the available opportunities for advanced training.

Within the organized network of competent care facilities and in the case of life-threatening body cavity injuries it is essential that the relevant expertise is available to diagnose and possibly deliver emergency treatment at very short notice in all hospitals qualified to care for the severely injured.

It is not only the advance of diagnostic and special therapeutic methods for the treatment of injuries to the abdominal and thoracic cavities with attendant specialization and concentration on special treatment apparatus, but also a drop in the number of life-threatening cavity injuries in recent years

that has sometimes led to a shortage in appropriate specialist care. According to calculations based

on the TraumaRegister DGU to determine frequency and management of abdominal and thoracic

cavity injuries, the statistics show that a doctor will only be confronted with this sort of injury every six to ten weeks whether the patient presents at a hospital for primary and routine care or at a maximum care facility.

These developments underline the need for additional training courses at suitable clinics making

good use of the TraumaNetzwerk DGU project as well as the increased need for advanced courses

in specialisms to impart specific knowledge related to the care of the severely injured and to prevent

treatment errors, especially in emergency situations (u.a. ATLS, ETC, DSTC, Hand over Team

Training [HOTT]).

2.4 References 1 Ruchholtz S, Lefering R, Paffrath T, Oestern HJ, Neugebauer E, Nast-Kolb D., Pape HC, Bouillon B.

Rckgang der Traumaletalitt. Ergebnisse des TraumaRegisters der Deutschen Gesellschaft fr Unfallchirurgie. Dtsch rztebl 2008; 105: 225231

2 Biewener A, Aschenbrenner U, Rammelt S, Grass R, Zwipp H. Impact of helicopter transport and hospital level on mortality of polytrauma patients. J Trauma 2004; 56 (1): 9498

3 Ruchholtz S. [External quality management in the clinical treatment of severely injured patients]. Unfallchirurg 2004; 107 (10): 835843

4 Hilbert P, Lefering R, Stuttmann R. Trauma care in Germany: major differences in case fatality rates between centers. Dtsch Arztebl Int 2010; 107 (26): 463469

5 Mand C, Muller T, Ruchholtz S, Kunzel A, Kuhne CA. Organizational, personnel and structural alterations due to participation in TraumaNetwork DGU: the first stocktaking. Unfallchirurg 2010; (online)

6 Bundesanstalt fr Arbeitsschutz und Arbeitsmedizin (2010). Unfallstatistik Unfalltote und Unfallverletzte 2008 in Deutschland.

7 Centers for Disease Control and Prevention: http://www.cdc.gov/injury/overview

8 TraumaRegisterDGU Annual Report 2011 for the year 2010 (in German). www.traumaregister.de/images/stories/downloads/jahresbericht_ 2011.pdf

9 Pirente N, Gregor A, Bouillon B, Neugebauer E. [Quality of life of severely injured patients 1 year after trauma. A matched-pair study compared with a healthy control group]. Unfallchirurg 2001; 104 (1): 5763


10 Grill E, Mittrach R, Muller M, Mutschler W, Schwarzkopf SR. [Systematic review of measurement instruments and concepts used for functioning outcome in multiple trauma]. Unfallchirurg 2010; 113 (6): 448455

11 Griffin JM, Friedemann-Sanchez G, Hall C, Phelan S, van RM. Families of patients with polytrauma: Understanding the evidence and charting a new research agenda. J Rehabil Res Dev 2009; 46 (6): 879892

12 Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. A systematic review of quality indicators for evaluating pediatric trauma care. Crit Care Med 2010; 38 (4): 11871196

13 Simmel S, Bhren V. [Surviving multiple traumawhat comes next? The rehabilitation of seriously injured patients]. Unfallchirurg 2009; 112 (11): 965974

14 Halcomb E, Daly J, Davidson P, Elliott D, Griffiths R. Life beyond severe traumatic injury: an integrative review of the literature. Aust Crit Care 2005; 18 (1): 1718, 2024

15 Christensen MC, Banner C, Lefering R, Vallejo-Torres L, Morris S. Quality of life after severe trauma: results from the global trauma trial with recombinant factor VII. J Trauma 2011; 70 (6): 15241531

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68 Knudson MM, Shagoury C, Lewis FR. Can adult trauma surgeons care for injured children? J Trauma 1992; 32 (6): 729737

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80 Edgar DW, Fish JS, Gomez M, Wood FM. Local and systemic treatments for acute edema after burn injury: a systematic review of the literature. J Burn Care Res 2011; 32 (2): 334347

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3 The concept of the TraumaNetzwerk DGU

3.1 Preliminary Remarks The treatment of the severely injured is medically demanding and timing is critical when life is

threatened (golden hour of shock) [1,2]. Consequently, correct, nationwide expert treatment must be streamlined according to the following factors: - the expected number of severely injured persons including regional and temporal peak periods,

and

- access to clinical facilities with the relevant performance spectrum (treatment capacity and expertise).

The aim of the TraumaNetzwerk DGU project is to ensure and continuously improve the quality and

reliability of care for the severely injured nationwide in Germany with the support of all experts and

groups involved in the care of the injured such as specialized professionals, associations and government institutions.

Every severely injured person should have the same chance of survival anywhere in Germany at any

time.


This can be achieved by means of a tiered organization that is cross-linked and enhanced by

networking structures connecting the approved facilities and requires: - Definition of standards for structures, processes, outcome quality and patient safety in the care of

the severely injured, - Contractual agreements to optimize and harmonize treatment standards, advanced training and

common strategies to improve outcome quality,

- Definition of criteria for expertise and capacity at the facilities linked into the networks according to their different treatment responsibilities,

- Definition of key criteria for referral of the injured person based on the type and severity of the injuries in cooperation with the leading medical rescue organizations (LRD) and definition of the need for treatment in a supraregional or regional trauma centre based on the S3 guidelines of the DGU to facilitate decision-making for the emergency doctor on site (www.awmf.de) [3],

- Expansion and intensification of the defined communication channels between all partners, including use of telecommunication.

Hospital infrastructure has been divided into three care categories that have been catalogued according to special structure and process criteria and given codes:

- local trauma centres, - regional trauma centres, - supraregional trauma centres.

Consequently, not all the existing institutions at each level will participate in the TraumaNetzwerk

DGU project in large conurbations, whereas some of the facilities in less densely populated areas

have to be upgraded to comply with the standards set by the TraumaNetzwerk DGU and to fulfil the

requirement of timely, expert emergency care.

Having secured the survival of the patient the next highest priority is the best possible restoration of

the functional and psychological integrity of same. For this reason rehabilitation centres and outpatient

treatment facilities must also be integrated into the concept of TraumaNetzwerk DGU.

3.2 Components of a Trauma Network The nationwide care of severely injured patients from the scene of the accident to the emergency clinic and then on to rehabilitation and follow-up treatment has to be guaranteed through a well coordinated collaboration between approved hospitals (emergency clinics and inpatient rehabilitation) and facilities for outpatient care in any given region. This includes establishing networks of clinics offering different

levels of care in the form of local, regional and supraregional trauma centres (TC). The concept of regional Trauma Networks (TNW) and the inclusion of clinics takes the following aspects into consideration: - regional peculiarities, - complete coverage of a geographical region with beneficial overlap into the margins of the

adjacent TNW, whereby clinics in any one region should belong to only one network,


- appropriate size of a TNW with a minimum requirement of one supraregional TC, two regional TCs

and three local TCs.

All the clinics in a TNW are audited as part of a certification process (quality assurance) to evaluate the requirements for care of the severely injured and their role within the trauma network.

The clinics are linked to each other and to the rescue services through a clearly defined

communication and cooperation system. Communication within the TNW is governed by contractual agreement and is an integral part of the network. Quality of care in the individual clinics and in the

TNW is evaluated partly on the basis of the data recorded and entered into the TraumaRegister DGU

on every severely injured person receiving treatment within each TNW. The cornerstone is to assess essential structural and procedural parameters and risk-adjusted mortality in terms of achieving the relevant benchmark.

Well structured cross-linking of the individual Trauma Networks must be strictly established and

regularly tested by conducting mock exercises involving all parties in order to ensure correct, expeditious, expert treatment in the case of a mass casualty event or a catastrophe.

The components of a Trauma Network are presented in detail in the next section.

3.3 Clinics in the Trauma Network

Local Trauma Centre (TC)

General Characteristics Local TC

The essential function of Local Trauma Centres is the nationwide care of the most frequent isolated

injuries. These centres also serve as the first point of contact, especially outside large conurbations, and fulfil the important task of adequate emergency care and best possible allocation of the severely injured person within their institution when primary transportation to a regional or supraregional trauma centre is not possible in the time available (obligation to admit). Their integration into a Trauma

Network obligates them to join with the regional and supraregional trauma centres in taking responsibility for immediate and follow-up treatment of relevant injuries and to participate in all subsequent treatment phases in accordance with regional circumstances and their individual performance spectrum.

Responsibilities within a TNW Local TC

The basic precondition for successful emergency care of the severely injured at a local trauma centre

on 24-hour standby is the ability and experience to recognize and control life-threatening abdominal bleeding (emergency laparotomy), thorax (emergency thoracotomy), and pelvis (application of an external fixator or pelvic clamp) and to address serious injuries to the extremities. The task of the local

trauma centre therefore consists of emergency treatment of life-threatening conditions (Damage Control Strategy) and reliable provision of transport to the next regional/supraregional trauma centre. The responsibilities can be detailed as follows:


- Guaranteed treatment of a severely injured person in the sense of emergency surgical

intervention, especially recognition and management of body cavity injuries and severe injuries to the trunk and extremities,

- Obligation to participate jointly in care and follow-up treatment with the regional and supraregional trauma centres,

- Optional participation in clinical studies,

- Participation in basic and advanced specialist courses, - Constant guarantee and improvement of care quality in the context of external and internal

general and special quality assurance procedures for trauma surgery.

Quality standards for infrastructure and procedure Local TC

- Clinic for Trauma Surgery, Clinic for Orthopaedics and Trauma Surgery or Clinic for Surgery with an orthopaedic/trauma expert,

- 24-hour standby for emergency admission of severely injured persons, - 24-hour availability (on call, present within 2030 minutes): Specialist for orthopaedics/trauma

surgery with an additional qualification in special trauma surgery or consultant for surgery specialized in trauma surgery,

- 24-hour availability (on call, present within 2030 minutes): Specialist for visceral or general

surgery, - 24-hour availability (on call, present within 2030 minutes): Specialist for anaesthesiology, - 24-hour standby for emergency admissions and emergency care of the severely injured, - 24-hour functional operating room for emergencies.

Personnel Requirements Local TC

Medical Management (Senior Consultant/Medical Director/Consultant) Local TC

- Specialist for orthopaedics/trauma surgery with additional qualification in special trauma surgery, or

- Specialist for surgery with a main focus on trauma surgery

Basic team in the emergency room Local TC

- 1 specialist for orthopaedics/trauma surgery or visceral or general surgery and/or specialty registrar* (MS-standard),

- 1 specialist for anaesthesiology and/or specialty registrar (MS-standard), - 2 nurses for surgery,

- 1 nurse for anaesthesiology,

* Of the trauma specialists responsible for emergency surgery (i.e. senior registrar and consultant) 50% must have an advanced qualification in emergency room management and a standard course in

Advanced Trauma Life Support-(ATLS). The DGU recommends participation in an ATLS course or

an ATLS equivalent course (e.g. ETC).


- 1 medical and technical radiology specialist (MTRA).

On-call emergency team (present within 20 minutes) Local TC

- Specialist for orthopaedics/trauma surgery with additional qualification in special trauma surgery (consultant)*,

- Specialist for visceral surgery or general surgery (consultant), - Specialist for anaesthesiology (consultant),

- Specialist for radiology (consultant), - 2 OR nurses.

Infrastructure Requirements Local TC

Emergency admissions Local TC

A local TC must have an emergency room. The relevant imaging equipment must be available at all times for prompt diagnosis and treatment of injuries, including life-threatening body cavity injuries. The emergency room must contain imaging equipment based either on x-ray or ultrasound technology or

CT. The emergency room must have its own independent heating system.

In the main interdisciplinary emergency centres there will be a jointly agreed protocol setting out responsibilities with regard to the emergency treatment of the severely injured.

Surgery Department Local TC

An operating room must be held in constant readiness for emergency surgery to treat a severely injured person.

Required installations Required installations Required installations Required installations are are are are listedlistedlistedlisted on p. 30 of the on p. 30 of the on p. 30 of the on p. 30 of the AAAAppendix.ppendix.ppendix.ppendix.

Intensive Care Unit Local TC

Provision must be made for temporary intensive medical care of the severely injured.

Regional Trauma Centre

General Characteristics Regional TC

Regional trauma centres are responsible for comprehensive emergency and definitive care of the

severely injured and maintain adequate intensive care and surgical facilities for this task. The necessary apparatus and human resources include the constant presence of specialists with advanced training in special trauma surgery, immediate access to consultants in other specialist disciplines (e.g. neurosurgery), diagnostic, therapeutic and surgical installations appropriate to this level of care, and participation in disaster control with provision of sufficient treatment capacity. It

differs from a supraregional trauma centre in that capacity is limited (emergency treatment area) and there are limited specialists for extremely complex injuries (e.g. thoracic aortic lesions).


Responsibilities within the Trauma Network Regional TC

In addition to the responsibilities of the local trauma centres a regional centre should be able to offer definitive treatment of the majority of injuries and their consequences. The responsibilities of a regional TC include:

- compulsory 24-hour admission and care of severely injured patients of any age, including very severe injuries,

- Constant presence of specified specialist consultants, - Obligation to offer medical care and follow-up treatment in collaboration with the local TC and

supraregional TC, - Participation in specialist professional development and advanced training,

- Participation in clinical studies, - Continuous improvements and guaranteed care quality in the context of external and internal

general and special quality assurance procedures for trauma surgery.

Quality standards for infrastructure and procedure Regional TC

- Clinic for Traumatology or Clinic for Orthopaedics and Trauma Surgery,

- 24-hour availability (on call, present within 2030 minutes): Specialist for orthopaedics/trauma surgery with an additional qualification in special trauma surgery or specialist for surgery with a main focus on trauma surgery,

- 24-hour availability (on call, present within 2030 minutes): Specialist for visceral or general surgery,

- 24-hour availability (on call, present within 2030 minutes): Specialist for anaesthesiology,

- 24-hour availability (on call, present within 2030 minutes): Specialist for radiology, - 24-hour availability (on call, present within 2030 minutes) neurotraumatology specialist (see

special text), - constant availability (on call, present within 2030 minutes) of all specialist departments involved

in the treatment of special injuries,

- 24-hour standby for emergency admissions to care for the severely injured, - 24-hour functional operating room for the definitive treatment of at least one severely injured

person, - 24-hour availability of appropriate intensive care capacity, - Participation in preclinical emergency rescue (rescue helicopter/clinicar).

Personnel Requirements Regional TC

Medical Management (Senior Consultant/Medical Director/Consultant)

- Consultant for orthopaedics/trauma surgery with additional qualification in special trauma surgery

or consultant for surgery specialized in trauma surgery, with at least 18-months experience in teaching special trauma surgery,


- Assistant: Specialist for orthopaedics/trauma surgery with additional qualification in special trauma

surgery or consultant for surgery specialized in trauma surgery.

Basic team in the emergency room Regional TC

- 1 specialist and/or specialty registrar for orthopaedics/trauma surgery* (MS-standard), - 1 specialty registrar in orthopaedics/trauma surgery, or visceral or general surgery*, - 1 specialist for anaesthesiology and/or specialty registrar (MS-standard),

- 1 specialist for radiology and/or specialty registrar (MS-standard), - 2 nurses for surgery, - 1 nurse for anaesthesiology, - 1 medical and technical radiology specialist (MTRA).

To cope with all types of injuries it must be possible to supplement the medical team by additional

specialists/consultants (extended emergency team):

On-call emergency team (present within 2030 minutes Regional TC

- Specialist for orthopaedics/trauma surgery with additional qualification in special trauma surgery (consultant)*,

- Specialist for visceral surgery or general surgery (consultant),

- Specialist for anaesthesiology (consultant), - Specialist for radiology (consultant), - Specialist for neurosurgery, - Specialist for vascular surgery, - 2 OR nurses.

Optional

- Specialist for ophthalmology, - Specialist for gynaecology, - Specialist for ENT, - Specialist for paediatric surgery and/or specialist paediatrician, - Specialist for oral maxillofacial surgery,

- Specialist for plastic surgery, - Specialist for thoracic surgery, - Specialist for urology, - Specialist with additional qualifications in hand surgery (Specialist for orthopaedics and trauma

surgery or specialist for plastic surgery).

Regional TC without its own neurosurgical clinic

Neurotraumatological emergency care must be guaranteed at all times at a regional TC. At hospitals without their own neurosurgery clinic/department neurotraumatological care is to be provided by one of

the means give

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